Sunday, 24 April 2016

Everyday crises

Death and taxes - the great unavoidables in life. Except, perhaps, if you have the phone number for a lawyer in Panama. Yet even the rich have yet to cheat death - it remains the great equaliser.

If 2016 is a bad year for celebrities, think for a moment about what it is that grabs us when one of them dies. The death of a celebrity prompts a bout of intoxicating nostalgia, that is not possible when they are alive. The loss of someone we feel we know (but haven't met) triggers some intangible emotions related to the fact that we have lost someone who didn't know they were important to us. Perhaps some of the grief is wrapped up in the realisation that they will never have the chance to know how important they were to us. Celebrities must have some abstract sense of the role they have played in other people's lives, but I doubt that they really grasp how resonant their song, book, film or art was to all their fans. Perhaps the sense of loss is more selfish - that the death of a celebrity reminds us of a bit our past that has gone for ever: reminds us that we are relentlessly marching in the same direction. I tie myself in knots thinking about it.

The manner of dying also has resonance: Bowie orchestrated a most stylish exit. Alan Rickman and Victoria Wood seem to have died privately, with friends and family around them. Prince was found in a lift. Marvin Gaye was shot by his father on his 45th birthday. Sean McGrotty died trying to rescue his family from a sinking car, after he had taken his 4 month old baby safely to the surface. The moment of dying is not just an ending, it is an epilogue to a life. It is the last thing you read in the book of someone's life, and it can colour or enhance everything that went before. 

I thought about this recently, when I heard that the body of Rose Polge had been found. All I know about her is that she was a junior doctor in Devon, and had last been seen in February; a note was found in her car. Who knows if being a doctor had anything to do with her death, but it sits there in the biography of her life as an emblem.

One's first years of practising medicine are an intoxicating mixture of pride, exhilaration, fear and exhaustion. While experiencing the thrill of diagnosing, prescribing and helping, there is also the worry, pressure and intensity. People always say that medicine is a tough job, but nothing prepares you for the reality of it. It is an odd and overwhelming feeling to be a doctor after the years spent chasing it. However, I found myself, for a time, hating parts of the job, and feeling wretched about it. It eased with time, but whenever I thought I had it sussed, something came along to unsettle me. Even now, I'm not quite sure how I made it through five years of being a medical registrar.

As I experienced self-doubt, and negative thoughts, I would look around me. All around me, I would see my peers seemingly sailing through with charm and style.  For a while as a house office, I went through some particularly hopeless periods. I wondered how I could feel so bitter about the people I was helping. I started to wonder if I cared enough about people to be a doctor. Interestingly, I started to find some perspective when I read 'House of God'. Samuel Shem's dark satire portrays a world so fancifully unrealistic, it is easy to dismiss it simply as black humour. But every hospital has a Fat Man,, who boils the world of medicine down to 13 simple rules. I had mine, and it was through him, I started to realise that I wasn't a bad doctor, I was simply a young doctor being asked to find his way through medicine without enough help. I wanted to be a Fat Man when I grew up. I guess we all do in a way: he is the one who makes it look easy. Yet even he went through his black periods, and perhaps the one thing that teaches us is never to trust the person who has never found it difficult.


There is nothing wrong with medicine being a challenging job. It is probably the lure of the challenge that draws so many in. It is therefore, unsurprising that many find it hard along the way: if we all found it easy, it would mean that it isn't that hard. What troubles me when I see it, is the failure to recognise and deal with stress and anxiety when we come across it at work. Who of us can truthfully say that we always help a struggling colleague whenever we find them? I often think about a house officer of mine who found the going tough when I was a registrar. I wanted to help her, but was barely keeping my head above water myself. I worked for a consultant who expected me to cope with everything that came my way. I often wonder what happened to her, and whether she made it through.

The challenge of supporting junior doctors gets confused because of how we think about junior doctors. The fact that we call them junior doctors illustrates the point. We treat them as students, and trainees, rather than fully functioning professionals. I prefer to think of them as colleagues. I prefer to think of them exactly as I think of other consultants, nurses and therapists. Of course, there are differences, but we shouldn't use these as an excuse for unjustified differences in how we treat them.

The hardest thing about dealing with junior doctors is their transience: they spend a few months with a team before moving on. There is little time to develop deep and trusting relationships. By the time you have understood how they are doing and what help they need, they are moving on. And this is the problem: we work with colleagues on the understanding that normally everything works well, but sometimes, we have to deal with problems.

The reality is that there are problems all the time. Dealing with challenges and stress is a daily part of the job, and should therefore be a daily part of the way we work.

From experiencing deep personal crises, I have learned that one of the most useless things to say to someone is 'You can ask me for help anytime.' One of the hallmarks of a crisis is not knowing how to ask for help, or how to approach a problem. The most helpful thing you can do for someone, is well, something helpful. You may not be able to solve the problem, but you can take away other things unrelated to the problem and increase their capacity for meeting the challenges ahead of them. I remember my Mum helping a neighbour who had lost her husband by doing her ironing. I thought it odd, but later realised, instead of offering sympathetic platitudes, she was doing something useful.

The most helpful thing that teams can do for junior doctors is to function in a way that allows the open contribution and discussion of problems and aspirations as part of the routine.

Personal sustainability in medicine is all about having the routines and habits that make a difficult job easier to bear, and teams who share the load. None of these skills is currently taught to junior doctors - they are expected to learn from people who themselves have never learned the good habits of personal sustainability. Is it any wonder then, that nothing seems to get better?

My goal is to ensure that the teams I work in communicate openly and honestly all the time; that we talk regularly about what is going well and what isn't; that we discuss what we want to do next, and we do it all together. I think, if we can do this, then any new member of staff, be it a junior doctor, healthcare assistant or nurse will join a team in which they know that they can learn, and struggle, and that all they support that they might ever need will not just be there when they ask for it, but given to them freely from the start.


Monday, 18 April 2016

Crowd-sourced trust

I have a snippet of a memory from many years ago. Aged 3 or 4, I am sitting in the back of a car - my parents are up front. There are novelties for all of us: it smells different, it is beige, it runs on diesel, it is Montego hire car. Remember the Montego? Outside it is foggy, snowing even, and it is bitterly cold. I hear my parents whisper to each other about it being too cold for a diesel car, that the fuel will freeze and we may well end up stranded on the side of the road.

For the rest of the journey, I am petrified. I give myself a pep-talk, telling myself how brave I am going to be if we break down and have to walk home. It never occurred to me to ask my parents if we were going to be OK - I had heard enough. And I dealt with my own fear by myself, because the last thing my worried parents needed was to have to deal with my own, small, child worries. Surely aged 3 or 4, I should be able to manage those for myself?

In the end, there was no crisis - the Montego defied expectations and carried on going, and we returned home without further incident.

I was thinking about that memory recently, as I drove to work on a cold, cold morning. And two things struck me: firstly, was it even a thing that diesel cars in the 80s would freeze if the ambient temperature dropped too low? I never saw it, I never see it now. Or was it that my parents had enough experience of British Leyland cars to know that if conditions fell off optimal then you could never be sure what the car would do. It's like the memory that in the 80s, whenever someone had a new car and you asked them how it was, they would always say 'It's too soon to tell.' You had to give them a couple of months to find out where all the gremlins were, which panels weren't properly fitted, which electrical components had been botched, and which bits of paint were going to flake off first.

I still see this in lots of my patients: the tacit acceptance that something brand new won't necessarily work well straight away. I think it might be why they take so much better care of their cars. They have the hard won knowledge from years of suffering well-designed, but terribly-made British cars, which unless they were cherished, polished, waxed and oiled, would seize up. They would look at the tide-mark of Dorset mud on the side of my car and shiver, I'm sure.

The second thing that this memory triggered was the realisation that my parents at that time had no idea how worried I was, and if I had mentioned it to them, they would have talked me through it, reassured me, and let me know that it would all be all right.

I often wonder how much I understand about what is worrying my patients. Sometimes I get a sense of what they aren't telling me, when one of them asks me a question, or does something so ordinary but unusual, that I begin to wonder whether a lot of their concerns never get asked, or aired. A man the other day interrupted my ward round review of him because he needed the loo. He was clearly desperate, but couldn't stop apologising afterwards. I couldn't reassure him enough that it was OK, that nobody should have to have an important conversation while bursting for a wee.

Another lady shyly asked me how her recent injury would affect some deeply personal aspect of her life. I was happy to advise her, but she was clearly mortified to have to ask, but still determined enough to do so.

This all begs the question, how do we give patients the confidence to ask, the time to be heard, and the confidence that they will be treated with compassion? I notice that so much emphasis is placed on my ward rounds by the patients that they get performance anxiety, and forget some of the things that they meant to ask. I encourage them to write their questions down when they occur, so that they don't slip their minds. But more than that, the thing I try to do now is to be present less formally. A ward round is quite a formal time: I go round the ward and see each patient in turn. They see me walk into the bay, and they wait their turn. Sometimes it must have the sense of an inspection, or progress report.

I have previously commented that my most fruitful relationships with patients are when we have a relationship on equal terms. They are them, and I am me, rather than a patient and a doctor. Honesty, to some extent, thrives on informality and familiarity; these are aspects of relationships that take time to build. and time is the one thing that we are not given enough of. I have 80 in-patients. If I spend just ten minutes with each of them, that is 13 hours a week.

Over time, I have learned that although my own relationship with my patients is important, it is not the only important relationship they have. They have close friends, and families; they have strong relationships with district nurses, therapists, their GPs. There are many people who have spent time with my patients over the years, and they are often well ahead in the trust-stakes with them.

Each moment I spend with them counts, but they are not the only moments that count. There are countless other opportunities to learn and understand. Effective team working enables this learning, and flat team hierarchies mean that it doesn't matter whether important conversations take place with a doctor, a nurse or a healthcare assistant - they can all be brought to bear for the patients' benefit as long as you have the trust in all the people you work with.


Tuesday, 12 April 2016

Crafting Care Plans

Legend has it that Voltaire wrote Candide in three days. Academic enquiry suggests it took a great deal longer. The idea that talent and perfection is innate has a peculiar traction, but it is perhaps lucky for most of us, that great works are more often the function of graft than inspiration. It is something that can give us all hope.

Novels take time to appear. I like to apply the Michelangelo idea to a book: the idea that a book starts as a solid block of paper, and the novel is chiseled out of the block in a process of rough outlining, correction and laborious polishing. It starts with the idea of what book is contained within, and the application of labour and skill to reveal the story concealed within. Reading Steinbeck or Nabokov or Conrad, one can certainly appreciate the process of refinement, and sense the bloody determination and brain-aching effort taken to phrase each sentence just so. 

Perfect prose has some of the hallmarks of a wonderful goal, or a breathtaking try. Before it happens you have the hope that it will work out the way you want. Afterwards, on the replays, it has the aura of something that always was, and was in some way always meant to be. 

My friend Charlie has written a wonderful (and beautiful) book (http://charliemaclean.co.uk/). It is actually more than just a good story, it is wonderful to hold and flick through. In the hand, there is the suggestion that it could only ever have been the way it turned out. But to know Charlie is to know the hours and the years that he put into crafting his first novel. It was a sacrifice to write, and a true labour. 

I know something of the commitment required: I have 70,000 words of almost complete twaddle sitting on my hard drive, waiting for me to find the courage to erase, and start again. Such is the experience of writing: one can go for miles and miles down one path before realising that it's the wrong one, and you need to go all the way back and start again. 

I thought of the creative process this afternoon, while engaged in a lively twitter discussion with David Oliver (@mancunianmedic) and Claire Solomon (@geridoclondon) about the wisdom of screening for frailty, without a clear plan of what to do with the knowledge that someone is frail. 

Within the world of geriatrics, it seems to be de rigeur to set up projects that screen patient groups for frailty. At a couple of events recently, I have listened to project after project describe how they are screening; but I have heard very little about what they do with that information. In many instances the process of screening is conflated for an actual comprehensive assessment, and what results from the whole process is a care plan, produced in one day, that is never updated, and almost certainly, rarely referred to again. 

Geriatricians deal with advanced frailty, and as David Oliver told me this afternoon, mild frail is about self-care and prevention, while  moderate frailty is about good primary care coordination. 

The question this poses me, as a community geriatrician, is what my role in all of this frailty management is. In reality, this question answers itself when I reflect on the patients that my capable and excellent local GPs ask me to see. Their referrals to me can be divided into three groups: those in whom they can't quite figure out what is going on (diagnostic uncertainty), those with complex symptoms in the context of multiple medical problems and those for whom the limits of medical intervention and treatment need to be considered (ie ceilings of care). 

The rest they mostly manage themselves. However, I have found that there is a useful role for me in this routine work, through the time I spend with GPs and MDTs, contributing to the discussions about patients and how we can best support them. 

Over the last two and a half years, I have learned a couple of important things about helping frail and vulnerable patients at home. 

The first is that success is defined by what the patient wants to achieve, and this can vary hugely. Some want to be pain free, others want to be able to breathe a bit easier. Some want to live long enough to go to their grand-daughters wedding or celebrate their ruby wedding anniversary. Others want never to have to see a doctor or go to hospital. And some simply want to die in comfort. There is no standard definition of success for these patients, and we can only know if we have done our jobs properly if we understand what it is that they wanted to achieve in the first place. 

Understanding patients to this kind of details takes time, and can't be achieved in one assessment or home visit. It takes patience, and commitment. 

And it takes something else: it requires you to listen, not just to the patient, but also to all the nurse, therapists and carers who have spent time with the patients, and formed a deep understanding of their issues and needs. 

Community MDTs need to function in a way that allows all team members who know the patients to be heard and to have the confidence to contribute; and care plans for these patients need to capture this information, and to evolve over time, as our understanding of individual patients grows and deepens. 

Care plans are not works of literature, but some of the same principles apply. Start at the beginning with a guiding concept, and over time, rework it, hone it and polish it. Make it a living document that everyone can refer to, contribute to and refer again to. 

Of course, behind every good book is a good editor, and perhaps the same is true of care plans. 

There is something of the chicken and egg about care plans: health professionals won't rely on them until they are readily accessible and contain useful information. GPs can be reluctant to spend much time on something that people can't access and don't use. 

Where I work, we have gone a long way to solving the accessibility issue. We just need to commit to both producing them, and using them. Of course, there are still barriers, but we won't get anywhere if we let that put us off.